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Mental Health Act

Volume 81: debated on Wednesday 19 June 1985

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Motion made, and Question proposed, That this House do now adjourn.—[ Mr. Neubert].

11.54 pm

I wish to draw attention in this short debate to what I believe to be a deficiency in the Mental Health Act 1983. Before going into what I believe to be the difficulties with the Act, I shall refer to a case which came to my attention in my constituency involving Mr. Lionel Clarke. I make no apologies for broadcasting his name, as I first heard about the case via the national television channels, so the background to his case is a matter of common knowledge.

Mr. Clarke, who is a negro in his 20s, has a long history of mental illness, and the social report produced by the Nottinghamshire county council shows that he has a background of aggression and that he is especially difficult to handle. This manifests itself in a number of violent tendencies. He has been in and out of a number of mental institutions. He was in Rampton, and after his discharge in 1980 he returned to his home and was peaceful for a while. However, in 1982 he threatened to kill his neighbour. He went back into a local mental hospital where he caused a considerable amount of damage, including tearing radiators from the hospital walls. His aggression increased over the years until in 1984 he broke down the door of his neighbour's house after he had been refused entry. He threatened his neighbour's children and had to be arrested by the police. It required 12 officers to detain him with a number of police cars and police dogs, and the incident caused a great deal of local concern.

Mr. Clarke was readmitted into Highbury hospital, which is a local mental hospital, and was released in July 1984. His mother was most concerned about his release and expressed her concern. She felt that she could not cope with someone of such violent tendencies living in her home. Her fears were justified, because a few weeks later he broke into his grandmother's house, broke it up, smashed up the cars of the police officers who came to detain him and generally caused havoc. In January 1985 he broke up his mother's house and threatened to kill her. He was remanded in custody for the damage which he had caused to his mother's house. As there were no suitable settings for him in the local health authority area he was put in Lincoln prison where he was remanded pending trial for the offences which he is believed to have committed.

It was against the seriousness of Mr. Clarke's background and the nature of his behaviour that Nottinghamshire county council prepared a report for the Nottinghamshire magistrates' court. The council decided that he was a definite risk to his family, to the neighbourhood and to the community generally. In preparing the report for the magistrates' court, no fewer than five psychiatrists were consulted over Mr. Clarke's condition. One psychiatrist came to the conclusion that, though he was a difficult person, he was not mentally ill. Of the other four, they all felt that he should be in a secure unit. Two of the four thought that that secure unit should be Rampton, which is under the control of the DHSS, which is an important feature in this case.

I shall quote a small extract from the consultant psychiatrist at Rampton. If he does not know what the matter with the man is, no one will. He wrote:
"I still consider that he presents a grave danger to others and that it is only a matter of time before he causes serious injury to someone. I consider that at the present time he needs treatment under the high degree of security, which is provided by Rampton Hospital."
Faced with reports of that nature, the Nottinghamshire magistrates decided that Mr. Clarke should be the subject of a hospitalisation order under section 57 of the Mental Health Act 1983. Under section 39, a request was made to the Nottingham health authority to provide the court with details of a secure setting for Mr. Clarke so that the magistrates could make a hospitalisation order and put him into a secure setting.

On 23 April the Nottingham health authority said that there was no suitable secure accommodation for Mr. Clarke in the region, or in any other region. Under section 39 of the Act the authority had been asked to provide details of a place in the region and the authority said that no spare place was available. It was not that a place could not be found but that the man was so dangerous and his condition so serious that suitable treatment could not be found in the region.

My information after that date is a little woolly, but someone then approached the DHSS, which controls Rampton, and said that the man should be admitted to Rampton. The DHSS admissions panel, in spite of the psychiatrists' report, decided that he should not be admitted to Rampton.

The magistrates were put in a difficulty because they could not keep the man on remand indefinitely. They had to try him. He was found guilty of offences and fined, and then—lo and behold—he was discharged. This was a man who a consultant psychiatrist at Rampton thought would eventually cause someone injury. No order was made.

This caused considerable concern to Mr. Clarke's family and the community. It attracted publicity. He was sent home with no obligation except to behave himself. That clearly could not continue, but it was not until his mother applied to start the process again that the man was taken to a local mental hospital. Within a month he was transferred to Rampton.

I have not mentioned civil liberties, because it is not appropriate, but civil liberties are a concern. I have not mentioned section 41 of the Mental Health Act, which places a duty upon the Home Secretary to protect the public's interest in such circumstances. The case that I have described shows that there is a lacuna in the operation of the Mental Health Act in that a man who is clearly mentally unwell can be set free.

I should like to ask some questions which if not answered tonight should eventually be answered. First, on what grounds did the DHSS refuse to admit the man to Rampton? The psychiatrist's report was available to the admission panel, but it was ignored. Secondly, why had the process to be restarted? Section 39 of the Act has been shown to be ineffective. The only obligation under that section seems to be to say whether a place is or is not available.

We should change the legislation to oblige the health authority to find a place for such a person. That was discussed in the Committee considering the measure and the Minister told the Committee that he would rather strengthen the guidelines than rely upon legislation. Clearly, those guidelines are not working. I hope that, if legislation is introduced, they will be reinforced. It is not sensible to set such people free on the streets and cause us great concern. I should like to know about the Department's plans to block this loophole, which cannot be left in its present position.

12.5 am

The Parliamentary Under-Secretary of State for Health and Social Security
(Mr. John Patten)

I am grateful to my hon. Friend the Member for Nottingham, North (Mr. Ottaway) for raising this point. He is rightly concerned about the welfare of one of his constituents, chat person's family, the community and those who might be adversely affected by his actions. I shall try to answer all my hon. Friend's points in relation to the particular case and by using the case as an illustration of our general difficulties. These difficulties arise not so much because of the Mental Health Act 1983 but because of the nature of a relatively small number of cases, such as that cited by my hon. Friend, which fall within the difficult-to-place or difficult-to-categorise categories or where there is a dispute between clinical specialists about the exact nature of the illness or handicap.

At least one other hon. Member will remember a similar debate a few weeks ago when my hon. Friend the Member for Plymouth, Drake (Miss Fookes) raised the case of a young woman who fell into a similar category. I should like to use some of the arguments tonight that I used then to show that better placement may be achieved not necessarily by a change in the law but by improvements in practice and better handling of difficult-to-place patients. We are dealing with a small handful of people in this respect.

A patient can be admitted to hospital for treatment if the hospital thinks that it can help and if the patient is willing to seek such help. The Mental Health Act is specific about detention. Ministers make no apology for the strictness of the criteria.

My hon. Friend said that he did not want to raise the civil liberties aspect and that this was not an appropriate occasion on which to discuss it. I have read with interest what he has said in the House on another occasion about civil liberties. It is important to remember that to deprive a person of his civil liberty is a serious matter. It is right that such a decision should be taken only after the most careful consideration.

I make no apology for the application of four strict criteria. The patient must be suffering from one or more—although not necessarily all—of the four forms of mental disorders set out in part I of the Mental Health Act and the mental disorder must be of a nature or degree that makes it appropriate for the patient to receive medical treatment in hospital. Ministers looking at those conditions are immediately and properly in the hands of medical advisers, clinicians and psychiatrists who make these judgments on society's behalf. It is not always easy for those judgments to be made clearly by medical authorities and it is sometimes very difficult for Ministers to make up their minds about particular cases. I would not wish to hide the difficulties that are faced by my right hon. Friend the Secretary of State and other Ministers in the Department. We spend a great amount of time trying to evaluate these cases.

Furthermore, it must be necessary under the Act for the health or safety of the patient or for the protection of others—in this case, my hon. Friend would probably say for both — that he or she receives this treatment, and it cannot be provided unless he or she is detained; for example, should the patient be unwilling to stay in hospital on a voluntary basis.

Whether those conditions are met in any case depends on at least two medical practitioners making the necessary recommendations. Provided all the conditions are met, the courts have the power, when dealing with someone who has committed offences punishable by imprisonment, to order admission to hospital under section 37 of the 1983 Act.

The Act did not, however—this point was debated at length during the passage of the measure; my hon. Friend has read the Committee proceedings and referred in his speech to some of those debates—confer on the courts the power to direct either a regional health authority to take or an individual doctor to treat a patient. Those who read the Committee proceedings will see why the Minister argued that that should be so.

Nevertheless, the ability of the courts to make hospital orders has been enhanced by the Act, especially by enabling them to get information from regional health authorities under section 39. That places a duty on regional health authorities to respond to requests from courts for information about a hospital or hospitals within its region or elsewhere which could give accommodation to a man or woman in respect of whom the courts are considering a hospital order. The section was specifically designed to help the courts to establish what facilities are available and which is the appropriate hospital catchment area for a patient.

Before coming to the question of patients, and to the particular patient to whom my hon. Friend referred, it might be of interest to the House if I give a resumé of the operation of the Act so far. In the past year the Department has monitored the occasions when section 39 has been invoked by the courts, and we have monitored the outcome. There have been only 29 requests for information by the courts. That represented just over half of cases, 18 patients, being admitted to NHS hospitals, some of whom might have fallen by the wayside and gone to prison instead had section 39 not existed. Thus far, therefore, for those 18 patients, there has been a considerable advance. The 29 references made by the courts gives a picture of the dimension of the problem—a relatively small number of people, but that is not to say that they are not an important handful of people.

I was confused when reading section 39 by the fact that no reference seems to be made to consideration of placing patients in very secure units, for use of a better expression, such as Rampton, which are under the control not of the local health authority but of the Department of Health and Social Security. How do those hospitals come within the ambit of section 39?

We have discretion to admit to special hospitals subject to the advice of the panel which assists Ministers.

It is true that an approach through section 39 is limited to the courts, and that answers my hon. Friend's question. But in the last two years the Department has taken its own initiative—because we have seen some of the problems—by having detailed discussions with each of the 14 health regions in the country involving senior officers of the NHS authorities, consultants and senior nursing staff from individual hospitals—we are indeed grateful to the nursing staff in some of these hospitals for dealing with patients who cause such difficulties—directors of social services and prison medical officers. We got all those people together and talked about this single category of difficult to place patients—those at the margin—and by getting those most concerned to look at the problem in that way, we have a much clearer picture of the total pattern of services and what developments are necessary to ensure that there is a comprehensive service in each region.

Further developments are needed in some regions, but some are not so much to do with bricks and mortar and staff as with a better understanding of how to manage some of these patients and redistribute them through separate hospitals in regional secure units or, as a matter of last resort, in places such as Rampton. There will always be cases that do not readily fit into the pattern of available facilities, so that will be problems in placement.

That leads me to the case that my hon. Friend has chosen as the subject for his debate. As I have explained before, I do not think that it is proper for me, as a Minister, and it may not be in the interests of the person concerned, to discuss the details of the individual case in public. Sometimes these details are highly personal. My hon. Friend dealt with great delicacy and sensitivity with a case that has already been widely broadcast. None the less, some points raise sensitive issues of confidentiality, and to answer those points I prefer to address my hon. Friend by letter. I am not trying to dodge the issue.

The case to which my hon. Friend refers is one in which the court clearly wanted to make a hospital order. However, it was prevented from doing so because the Trent regional health authority could not offer a hospital placement either in its region or elsewhere. The court had requested information under section 39. My right hon. Friend the Secretary of State did not consider that a special hospital place was appropriate. My hon. Friend has outlined the sequence of events, and how that decision came to be taken. He has also asked some questions which involve confidentiality and individual details, and I shall write to him about them.

The court had no option but to impose a custodial sentence. Because of the period spent on remand, the man concerned was released back into the community. However, in this case there had been some disagreement between doctors about the nature of the mental disorder. Sometimes, cases that to lay people look like mental illness may be cases of mental handicap, with additional behavioural problems. Such considerations bore on the region's decision not to offer a place in its secure unit.

In the event, although strictly speaking treatment in a maximum security unit was not warranted, my right hon. and learned friend the Minister for Health intervened speedily after my hon. Friend's concern was made known and asked if, after looking at the case again, the region decided that it could not look after the man, a place at Rampton should be made available. We try to act as sensitively as possible on individual cases causing concern, such as this, when the way in which the law has worked has left someone falling between all the available stools.

After further detailed discussions between my Department and the region, the latter, still not being prepared to offer a permanent hospital place, offered a bed as a temporary measure in a local hospital, and the patient was therefore transferred to Rampton hospital. He is there now, and treatment is available from skilled staff for that man who needs our help. That also means that the people from the area from which he came—neighbours and relatives—who were concerned, have no more reason to be concerned, and that is important.

On the wider issues, I hope that I have said enough to demonstrate that there has been some real progress under the Mental Health Act, even if my hon. Friend feels that in this case that progress has not been shown.

I shall certainly consider the point that my hon. Friend made about the possibility of there being a lacuna in the law. Many, if not all, of the problems caused by difficult-to-place patients, where section 39 is involved, will during the next few years be greatly aided by the considerable progress that we are making by keeping in close touch with all the people in the different categories that I listed, who are concerned with this small but important minority of patients who do not fit readily into any system. I suspect that we shall never design a perfect legal system to encompass all those whose needs must be tackled on an individual basis.

Question put and agreed to.

Adjourned accordingly at twenty minutes past Twelve o' clock.